Laparoscopic Pancreatoduodenectomy for Pancreatic Cancer Using In-Situ No-Touch Isolation Technique

Summary

No-Touch isolation procedures might prevent the dissemination of cancer cells from the primary tumor. However, these techniques are not widely accepted in laparoscopic pancreatoduodenectomy (LPD) by now. We herein present in-situ No-Touch isolation LPD with partial resection and reconstruction of the superior mesenteric vein (SMV) for pancreatic cancer after neoadjuvant therapy.

Abstract

Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic resection and reconstruction techniques, it is difficult to perform LPD for patients with locally advanced pancreatic head cancer after neoadjuvant therapy. Our team initiates LPD using the in-situ No-Touch isolation technique. The innovation and optimization of this modified No-Touch isolation technique emphasize exploring the distal section of superior mesenteric vein (SMV) and the left side of the superior mesenteric artery (SMA) prior to evaluating the resectability by subcolonic mesenteric approach, which is an ideal exploring approach. After that, we use the median-anterior, and left-posterior of SMA approaches to cut off the blood flow of the pancreatic head to make the tumor isolated intact, then move and dissect the tumor. It is a process fitting the surgical principle of tumor-free. This article aims to demonstrate the feasibility and safety of performing LPD using the in-situ No-Touch isolation technique, which might elevate the R0 resection rate. It is an oncological ideal operation process.

Introduction

Pancreaticoduodenectomy (PD) is a standard surgical procedure for cancer in the pancreaticoduodenal region. The Kocher maneuver is widely used for the efficient exposure of the duodenum and pancreatic head during conventional PD. The mobilization and squeezing of the pancreaticoduodenal area during surgery may cause metastasis of the tumor cells before the ligation of surrounding vessels¹. A recent study had shown that the tumor cells had the potential possibility of being squeezed into the portal vein (PV) because of the handling and squeezing of the tumor area by the surgeons, which might further increase the risk of liver metastasis after surgery².

With the development of biomedical technology, a scientist could detect the spread of solid tumor cells, including pancreatic cancer cells, into the vessels as circulating tumor cells (CTC)^3,4.

No-Touch isolation procedures, which have been used in colon cancer, might prevent the dissemination of cancer cells, such as circulating tumor cells, from the primary tumor⁵. Several studies have reported the use of a no-touch isolation technique for pancreatic head cancer during laparotomy pancreaticoduodenectomy^6,7. The concept of this procedure is that the surgeon does not touch the duodenum and pancreatic head region (including the tumor) before ligating and dissecting the vessels (arteries and veins) around the pancreatic head.

No-Touch isolation techniques have been reported in LPD for pancreaticoduodenal region neoplasm⁸. We herein present a modified in-situ No-Touch isolation LPD with partial resection and reconstruction of SMV for pancreatic cancer after neoadjuvant therapy, which dissects all the inflow arteries first, transects the involved vein with sufficient margin, resects the tumor in-situ, and removes the specimen en-bloc.

The goal and advantages of this method are to ensure that all steps follow the oncologic principles of No-Touch in order to decrease the risk of metastasis of the tumor cells. The rationale behind the development and use of this technique is that the tumor should be mobilized at the final stage, including resecting the tumor in situ and removing the specimen en bloc after tumor inflow arteries and outflow veins are occluded. However, as this procedure requires complex resection and reconstruction techniques when surgeons decide whether to use this method, they need to estimate their own situations such as the learning curve, tumor type, vascular condition, and other factors.

Protocol

This study was permitted by the Ethics Committee of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine.

1. Patient selection

1. Advise the patients suspected of suffering pancreatic ductal adenocarcinoma (PDAC) in the pancreas head to take a contrast-enhanced computed tomography (CT) scan at first. Then select the following patients: borderline resectable cases after neoadjuvant therapy, tumor regresses significantly and has the possibility of radical resection; meanwhile, SMV reconstruction is potentially needed.
2. Exclude the following patients: (1) metastatic PDAC; (2) patients with a poor general condition that cannot tolerate major surgery; (3) vascular involvement of SMA, common hepatic artery (CHA), or celiac artery (CA).

2. Surgical technique

1. Operative setting
   1. Place the anesthetized patient in a completely supine position, with legs spread out.
   2. During the sterile exposition, ensure that the suprapubic region is exposed adequately for the later specimen removal by a Pfannenstiel incision. Ensure that the operator surgeon stands on the right side, the first assistant is on the left side, and the second assistant holding the laparoscope is positioned between the patient's legs. Use the 5-port technique to perform the procedure (Figure 1).
   3. After the pneumoperitoneum is created, introduce the rigid laparoscope through the sub-umbilical 12 mm trocar, and place the other four trocars along a semi-circle.
2. Exploration phase
   1. Explore the intraperitoneal organs and peritoneal surfaces meticulously for unexpected extrapancreatic metastases.
   2. Resect the greater omentum and open the lesser sac by dividing the gastrocolic ligament.
   3. Ligate Henle's gastrocolic trunk vein. Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas.
      NOTE: The tunnel between the pancreatic neck and SMV can not be created easily if the anterior wall of SMV is involved.
3. Dissection phase:
   1. Subcolonic mesenteric approach: For this approach, follow steps 2.3.2-2.3.5.
   2. After the transverse colon and its mesentery are elevated cephalad, place the entire small bowel on the left side to facilitate exposure of the pancreaticoduodenal region.
   3. Expose the second and third parts of the duodenum after the mesentery section.
   4. In order to reconfirm resectability and mobilize the posterior of the pancreatic head, expose the inferior vena cava (IVC), left renal vein (LRV), celiac trunk, aorta, and SMA (Figure 2).
   5. Then perform the dissection along the SMV to clear all the tissues on the right side. In order to expose the SMV fully, ligate the root of the middle colonic artery after confirming that there is no ischemia in the transverse colon.
   6. Left posterior of SMA approach: For this approach, follow steps 2.3.7-2.3.18.
   7. Place the entire small bowel on the left side to facilitate exposure and the dissection of the distal duodenum proximal to the ligament of Treitz.
   8. Divide the proximal jejunum with a stapler.
   9. Expose the SMA by tracing along the jejunal artery.
   10. Place a Fr8 catheter for hanging for encircling the dorsal aspect of the SMA and SMV.
   11. Pull the catheter to the upper right side to allow SMA dissection on its periadventitial plane on the anterior-left margin and its separation from the mesopancreas.
   12. Ligate the first jejunal artery (FJA) involved by the tumor and sacrifice.
   13. Identify the first jejunal vein (FJV) and the inferior pancreaticoduodenal veins (IPDV), which are the branches from the dorsal side of the SMV.
   14. Ligate and dissect the IPDV.
   15. Circumferentially dissect the SMA to identify the inferior pancreaticoduodenal artery (IPDA), which either forms a common trunk with the FJA or arises directly from the SMA (Figure 3).
   16. Sacrifice the IPDA.
   17. At the left posterior approach, dissect the SMA, which is identified at its origin above the LRV, free from the mesopancreas.
   18. In cases that the tumor invades the mesocolon, hang the SMV and SMA through a rubber band followed by coring out of the mesocolon.
   19. Supracolic median-anterior of SMA approach: For this approach, follow steps 2.3.20-2.3.34.
   20. Start the SMA approach from the upper colon region.
   21. Explore the gap between the pancreatic neck and SMV at the lower edge of the pancreas.
   22. Use a stapler device to divide the stomach 3-5 cm away from the pylorus.
   23. Remove the gallbladder.
   24. Divide the common bile duct (CBD) as conventional PD. Take a frozen pathologic examination of the bile duct stump. Apply the laparoscopic bulldog clamps to occlude the CBD temporarily.
   25. Dissect the hepatoduodenal ligament. Perform a lymphadenectomy along the CHA, the proper hepatic artery (PHA), and the PV.
   26. Ligate and dissect the right gastric artery.
   27. Identify the gastroduodenal artery (GDA) at the point where the PHA branches from the CHA.
   28. Doubly ligate or suture the GDA to minimize the chance of subsequent erosion and bleeding.
   29. Transect the neck of the pancreas with an ultrasound knife. Take a frozen pathologic examination of the pancreatic stump.
   30. Suspend the splenic vein (PV) using a rubber band.
   31. Set up a diamond-shaped window by retracting the transverse mesocolon caudally, the PV cranially, the SMV rightward, and the SMA leftward.
   32. During the supracolic median-anterior of the SMA approach, dissect the right and dorsal aspects of the SMA within this diamond-shaped window.
   33. Resect the fat and fibrous tissues around SMA and CA from the caudal side to the cephalic side.
   34. Ligate and transect the uncinate process artery (UPA) under the PV, leaving the specimen attached to the PV/SMV.
   35. Combining with median-anterior and left-posterior approaches to the SMA, expose the origin of the IPDA or the common trunk of the IPDA and FJA easily.
       NOTE: During this procedure, the GDA, UPA, and IPDA have been completely ligated. Furthermore, all the tumor artery inflows are completely occluded till this moment to reduce bleeding.
   36. Use laparoscopic bulldog clamps to temporarily clamp the PV, the splenic vein, and the SMV. Transect the involved vein with sufficient margin.
   37. Afterward, cut off the lymphatics and dissect the duodenum from the retroperitoneum.
   38. Finally, resect the tumor in situ and remove en bloc following the oncologic principles of No-Touch^2,6,7.
4. Reconstruction phase
   1. Measure the length of the venous defect with a soft ruler. If the defect exceeds 3 cm, consider using an artificial interposition graft.
   2. Perform SMV reconstruction from caudal to cephalic by continuous suture using 5-0 prolene sutures (Figure 4).
   3. Reconstruct the digestive tract by Child's method⁹.
   4. An end-to-side, perform single-layer running suturing hepaticojejunostomy with 4-0 absorbable sutures.
   5. Conduct pancreatic anastomosis by duct-to-mucosal, end-to-side pancreaticojejunostomy within an internal stent⁹.
   6. After a side-to-side gastrojejunal anastomosis, place three drainages near the anastomosis.
5. Bag the specimen and retrieve it through the Pfannenstiel incision.

Results

A 55-year-old man with upper abdominal pain and marasmus was diagnosed with a 4.2 cm x 3.1 cm tumor in the uncinate process of the pancreas, and the SMV was involved over 180° (Figure 5). The patient was previously healthy and had a relatively normal body mass index (19.47 kg/m²). No distant metastasis was found on the preoperative contrast-enhanced CT scan. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed to acquire the pathology diagnosis of adenocarci...

Discussion

PDAC is one of the most lethal malignant diseases. Despite the fact that the overall 5-year survival rates are still unsatisfactory, surgery remains the only curative therapeutic method till now¹⁰. According to the National Comprehensive Cancer Network (NCCN) and International Study Group of Pancreatic Cancer (ISGPS), patients diagnosed with PDAC should be defined as borderline resectable cases while the portal-superior mesenteric vein is suspiciously involved, and in order to improve R0 resection...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
3D Laparoscope	STORZ	TC200,TC302
Absorbable hemostat	ETHICON, LLC	2 in x 4 in
Artificial Interposition Graft	W.L.Gore & Associates, Inc.	IRTH084040W
Drainage tube	Aiyuan	424280
Echelon Flex Powered Plus Articulating Endoscopic Linear Cutter and Endopath Echelon Endoscopic Linear Cutter Reloads with Gripping Surface Technology	Ethicon Endo-Surgery	ECR60G/GST60G
Energy Platform	COVIDIEN ForceTriad Energy Platform	T2131469EX
HARMONIC ACE Ultrasonic Surgical Devices	Ethicon Endo-Surgery	HAR36
Laparoscopic forceps	Gimmi
Laparoscopic right angle forceps	KARL STORZ
Laparoscopic scissors	AESCULAP
Latex T-shape Catheter	ZHANJIANG STAR ENTERPRISE CO., LTD.	24Fr
Ligating Clips	Teleflex Medical	5,44,22,05,44,23,05,44,000
PDSII	Ethicon, LLC	W9109
PROLENE	Ethicon, LLC	W8556
Trocar	Surgaid	NPCS-100-1-12
Ultrasonic Surgical & Electrosurgical Generator	Ethicon Endo-Surgery	GEN11CN